Provider Demographics
NPI:1235861451
Name:IMPERIAL SUPPORT COORDINATION
Entity Type:Organization
Organization Name:IMPERIAL SUPPORT COORDINATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KUKUBOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-595-3597
Mailing Address - Street 1:183 JOHNSTON DR
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-4927
Mailing Address - Country:US
Mailing Address - Phone:347-595-3597
Mailing Address - Fax:
Practice Address - Street 1:183 JOHNSTON DR
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-4927
Practice Address - Country:US
Practice Address - Phone:347-595-3597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care